Why medical students need to begin in the classroom

My esteemed colleague Dr. Bob Centor is enamored of an interesting essay from which he quotes:”Only you can educate you—and you can’t do it by memorizing. You have to find out who you are by experience and by risk-­taking, then pursue your own nature intensely. School routines are set up to discourage you from self-discovery. People who know who they are make trouble for schools.”

Personally, I found it more of a screed against bad education which, taken too much to heart, leads to more useless college degrees in navel-gazing and ever-decreasing mastery of the basics. I wonder how the classically-educated essay author would feel about students who refused to read any book, preferring to watch YouTube versions of Cliff Notes because they’re just “taking control of their education.”

Dr. Centor, though, goes on to apply these thoughts to medical education:

Long time readers know that I dislike how we teach basic sciences in the first two years of medical school. They also know that I generally love the 3rd year (the clinical rotation year). I believe that this essay speaks to my biases…

The potential beauty of medicine’s clinical training comes from the opportunity that it provides our learners. The patients provide learning opportunities. We who teach those learners can help them if we understand that our main responsibility comes in sharing the thought process.

While I respect Dr. Centor immensely, in this case I think he’s a little bit off base. There is a certain amount of basic knowledge required to make sense of what you see in the patient. That’s why they’re called the “basic sciences.” I think Dr. Centor is forgetting that students must learn to walk before they can run, even as it is our job to mold them into competent runners.

For example, it would be impossible to have a meaningful discussion of an acid-base balance problem (a topic near and dear to Dr. Bob’s heart) before a student has learned renal physiology, plus respiratory physiology (respiratory compensation) as well as perhaps some GI pathology (vomiting and diarrhea). I find myself wondering how much contact Dr. Bob has had with pre-clinical students, beyond the tag-along, see-what-it’s-like experiences so widely touted these days as a means of maintaining students’ idealism and focus on the long term. I have, and I think it has brought me a different perspective.

Recently I had the experience of precepting a first-year student during a required “primary care practicum.” He had been taught the rudiments of interviewing, as well as most of the first year of the basic sciences. No pathology; no pharmacology; only a few parts of the physical exam. And yet he was tasked with taking the HPI on several patients a day, as well as identifying “learning issues” related to the basic sciences he’d already studied. Don’t get me wrong: the student was excellent. He was compassionate, bright, and a very hard worker. But his interviews were stilted and awkward (even though he didn’t take notes, made great eye contact, and had excellent body language). I quickly figured out what the problem was: although he had been taught what questions to ask, he had no idea what kind of answers to expect. And when taking a history, each answer helps you formulate the next question. Without the full complement of the basic sciences, the poor thing was lost.

I believe I was able to teach him a great deal, but most of it felt so superficial as to be almost useless. I invited him to come back again once he’d finished the second year, when at least we could discuss pathophysiology, and again after he’d spent some time in the hospital, to get a better sense of what ambulatory medicine is all about.

I agree that for the student, it is tremendously frustrating to spend hours learning (not memorizing; learning and understanding) all the minutiae that is biochemistry, physiology, pathology, etc. Two years can feel like forever. Still, without a certain level of basic knowledge, all the deep insights of the greatest clinicians will be lost on the learners.

I agree that medical education’s basic science curriculum needs revamping, and would definitely be improved by increasing the involvement of actual clinicians at all stages, from curriculum design to classroom and laboratory instruction. But medical students need to begin in the classroom before they can appreciate the bedside.

Physician Coaching by KevinMD

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DocXology

“I consider that a man’s brain originally is like a little empty attic, and you have to stock it with such furniture as you choose. A fool takes in all the lumber of every sort that he comes across, so that the knowledge which might be useful to him gets crowded out, or at best is jumbled up with a lot of other things, so that he has a difficulty in laying his hands upon it.”

Sherlock Holmes in “A Study in Scarlet” by Sir Arthur Conan Doyle

Over the years I have reflected on the state of medical eduation as successive generations of students, junior medical officers and specialists-in-training have passed my way. And a constant pattern keeps re-emerging. Knowledge is often fragmented, connections are not made between concepts or across disciplines, clinical practice is devoid of scientific rationale and practical application is patchy and undisciplined.

This passing week I ran a couple biomedical tutorials for our Primary exam candidates. The Emergency Medicine Primary Exam comprises of four subjects – Anatomy, Physiology, Pharmacology and Pathology. Similar exams are given to trainees in Surgery, Anaesthesia and Intensive Care Medicine. What surprised me was that despite a reasonable grasp of the basic principles of these disciplines, my group really struggled in seeing the relevance or application these had to their daily clinical practice. For example they had trouble in using fundamental concepts in pharmacodynamics or pharmacokinetics to explain and inform them on common scenarios involving drug dose adjustment, effective routes of administration, clinical onset and duration of action and interactions with other agents.

My expectations may have been different if they were medical students with little to no clinical experience on which to relate their knowledge but these were clinicians with at least of 2-3 years of experience who not only would have covered these subjects in medical school but subsequently would have come across a wide variety of practical situations in which they could have employed this knowledge. And this is not an uncommon situation observed in trainees across a number of specialties, at different levels of training, including some at a surprisingly high level of seniority. To some degree all these doctors function at a reasonably safe and relatively independent level in most situations. Nonetheless, I am somewhat discomforted by the thought that because they don’t have a firm grasp of some core concepts of biomedical science, their ability to deal with unusual or atypical problems is compromised by these deficits. I suspect most of these clinicians get by because the law of averages will state that common things are common and in most cases both pure pattern recognition and probabilities allow a clinician to choose the correct diagnosis and management. The difficulty arises when the presentation varies from the norm. The temptation is then to (force) fit the clinical picture to the proposed diagnosis rather than the other way round. They often lack skills (or knowledge) to ‘reason’ from first principles in a way to alert them to the fact that there are blatant contradictions to their original line of thinking.

All of this has caused me to wonder why this has become such a recurrent, persistent and systemic phenomenon in clinical practise. Interestingly, the medical education literature is full of references to terms such as ‘vertical’ and ‘horizontal integration’. The former relates to the relationship between formal theory e.g. pathophysiology, psychology, ethics; and real-world practice e.g. clinical medicine, the therapeutic relationship, professional behaviour. The second refers to how to reconcile apparently completely unrelated paradigms across disciplines e.g. medical care and medico-legal obligations in determining the best of action. Despite major changes to the delivery of medical curricula over the last twenty years. I wonder if we have really achieved the holy grail of true integration. At the undergraduate level, the dramatic revolution has been the switch from didactic programming to problem- or case- based, student driven learning. At the post-graduate level, many specialist colleges in the UK are changing (and our College presently so) to more clinically-relevant evaluations of biomedical knowledge. Anecdotal experience suggests neither have seemed to have fully addressed the problem. There is probably not one sufficient explanation but I suspect an important factor is that neither erudite scientists or experienced clinicians are properly informed about each other’s disciplines to be able teach in the context of the other’s knowledge base. With such a major deficiency in educators to teach in this manner, one could take the nihilist view that we are wasting both faculty and student time by teaching the sciences when frequently it is unable to be utilised or consequently forgotten.

I believe another contributing factor to this issue is the misuse of the concept of ‘evidence based medicine’. The term was coined by Dr. David Sackett as is defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Personally, I have nothing against the idea and in fact fully support it as a concept. Unfortunately, it has been somewhat hijacked and distorted by some hospital administrators, clinical leaders and medical interest groups to create a sterile (and sometimes dangerous) uniformity to patient assessment and care. Selective portions of the literature are massaged into ‘clinical guidelines’ and ‘protocols’ that become edicts not to be broken rather than illuminating points of knowledge. Any informed reader of the medical literature will quickly realise that the interpretation of various studies (including RCTs) needed to be interpreted within the population context in which they are derived. The relevance and significance of a treatment is not based simply on the diagnosis of the condition. The treatment effect even if positive often demonstrates wide confidence limits. It may be altered by factors including but not limited to the severity of the condition, previously administered or concurrent treatments, the real world compliance of the patient and the additional health resources available. Herein lies the ‘art’ of the clinician who gathers and weighs a whole range of considerations prior to determining the best course for an individual patient. However, it seems that this important process is somewhat overlooked by those who are so eager to put these medical ‘cookbooks’ into circulation. They tend to cater to the lowest denominator with not colour and nuance in their recommendations. The unfortunate consequence is that junior clinicians are no longer taught (or encouraged) to ‘think’. Reward (and reprimand) are based more on ‘following the guidelines’ then to either sound clinical reasoning or just plain commonsense. I am not totally opposed to the development of such manuals particularly in environments where doctors are relatively inexperienced. Generally, they are conservative in approach and err on the side of over-investigation, over-treatment or over-referral. However, in the process they can generate a lot of wasted time and effort – an important factor to consider in resource-stretched health system. More concerning is when a patient is treated by a protocol for a disease they do not actually have – and not treated properly for the one they do. But in terms of training, these directives can be incredibly stifling to the academic development of doctors who may begin to perceive all the complexities of true clinical practise yet do not possess the reasoning tools to navigate them. This then leads to a vicious circle where providing simple guidelines become necessary because our doctors are either able or trained to think.

The answers to these problems will not come easy but it must sure come from better collaboration between those in basic research and clinical practise such that these relationships translate into better content delivery – and also between clinicians from different disciplines and practise environments. But challenge is not becoming any easier. New areas of research and disciplines are constantly developing. This has been paralleled with the evolution of an ever increasing number of clinical super-specialties. No where in the history of medicine has there been such a pressing need to rationalise this knowledge into a digestible form for our embryonic and undifferentiated doctors of the future.

“Clinicians in many branches of medicine find that their work demands an extensive knowledge of respiratory physiology. This applies to anaesthetists working in the operating theatre or in the intensive care unit. It is unfortunately common experience that respiratory physiology learned in the preclinical years proves to be an incomplete preparation for the clinical field. Indeed, the emphasis of the preclinical course seems, in many cases, to be out of tune with the practical problems to be faced after qualification and specialization. Much that is taught does not apply to man in the clinical environment while, on the other hand a great many physiological problems highly relevant to the survival of patients finds no place in the curriculum. It is hoped that new approaches to the teaching of medicine may overcome this dichotomy and that, in particular, much will be gained from the integration of physiology with clinical teaching.

This book is designed to bridge the gap between pure respiratory physiology and the treatment of patients. It is neither a primer of respiratory physiology nor a practical manual for use in the wards and operating theatres.”

It is the same in nursing. As an instructor and nurse all I heard was “critical thinking skills”. Students are not able to think in this manner until they are well versed in the basics. I was unable to understand how an anatomy student could apply much critical thinking in this area. The anatomy of the human body has remained pretty much the same since man has walked on two feet.
Sudents need to locate and understand the function of the skeletal structure in order to identify landmarks and assess dysfunction.

pj

Why cant we have a happy medium? Early (from day one) rounding in hospitals and clinics to observe and ask discrete questions, without the silliness of doing several HPI’s daily. That was simnply the wrong way to integrate clinical, real world experience into the process. Let’s not throw out the baby w/the bathwater. Early integration would’ve helped me better remember the basic sciences due to seeing them in real world use,